Continuing medical education (CME), the third, final, and lengthiest phase of physician education, has expanded dramatically since the first reported CME undertaking in 1935.1, 2 In the United States today, CME is a $3 billion annual expenditure.3 CME has been defined as "any education or training which serves to maintain or develop or increase the knowledge, interpretive and reasoning proficiencies, applicable technical skills, professional performance standards or ability for interpersonal relationships that a physician uses to provide the services needed by patients and the public."4
Nel and Kent4 advised that successful CME should (1) be needs driven and take cognizance of individual differences, (2) have clear behavioral objectives, (3) provide opportunity for discussion and participation, (4) provide corrective feedback and/or reinforcement, and (5) allow for individualization of programs.
In the medical specialty of physical medicine and rehabilitation (PM&R), CME issues obviously must be addressed. In the early 1980s, Coldeway and DeLisa5 eloquently discussed educational needs assessment as the foundation for CME. Surveys of either current residents6 or recent graduates7 have revealed areas of unmet educational needs from the perspective of younger physiatrists. Information from the American Academy of Physical Medicine and Rehabilitation (AAPM&R)8 reveals that almost two-thirds of fellows have been certified in the past 15 yr. In a 1993 study of PM&R residents, Kerrigan et al.6 found that residents desired more clinical and didactic experience in several areas, including industrial medicine, sports medicine, computer applications, therapeutic injections, and administration. In a survey of recent graduates, Howell et al.7 indicated that musculoskeletal medicine was the topic that was most desired for further training/education. Unfortunately, absent in the PM&R literature are studies comparing academicians and private practitioners, women and men, and recent and earlier residency graduates. Similarly, analysis of physicians' perspectives of relevant planning issues for organizing CME activities are lacking.
Clearly, the planning and delivery of appropriate CME for physiatrists are complex. The CME committee of a large, established PM&R program surveyed all of its former residents to obtain information for planning targeted, relevant CME activities. For comparison purposes, current residents were surveyed as well. In addition to determining demographic data, practice patterns, and current educational needs, the survey was designed to differentiate the educational needs of recent and earlier graduates of the program.
A survey was sent to the 168 physicians who had completed the PM&R residency program at Baylor College of Medicine (BCM) in Houston, Texas, since its inception in 1961 through 1995. In addition, it was given to all 34 then current (Spring 1996) residents in the program. A cover letter requesting completion of the survey explained that the survey would serve at least three purposes: (1) assessing the effectiveness of the BCM PM&R residency program in preparing physiatrists for their current positions, (2) ensuring that future CME programs address the needs of physiatrists, and (3) assisting others in the field to structure effective educational programs through dissemination of the survey results. It assured the respondents that all data would be kept confidential and that only the three authors would have access to individual responses.
The survey consisted of 19 major questions, some with as many as 99 subparts. Questions were asked regarding gender, year of completion of residency, certification, fellowships, type of current employment situation, size of practice community, work time distribution, organizational membership, and busiest areas of clinical practice. Respondents were asked to rate separately, on a 5-point scale (1 = poor, 5 = excellent), their clinical and didactic learning experiences during residency training with regard to 47 topics plus "other," which they specified. The topics included medical conditions, psychosocial issues, research and teaching issues, and administrative issues. For the same 47 topics plus other, the respondents indicated in which topics (up to 10) they had a current strong interest in continuing their education. In addition, the survey included questions about the respondents' three most important considerations (from a list of nine items plus other) when deliberating about attending an educational activity, the amount of notice required regarding an upcoming course, and the preferred duration of educational activities.
Descriptive information was analyzed for all variables, including characteristics of the sample, busiest areas of clinical practice, and most important considerations for attending an educational activity.
For the purposes of this article, the remaining analyses focused on topics of interest for continuing education. First, the percentage of all respondents interested in each topic was assessed. Second, significant differences in interests were identified based on (1) gender, (2) former or current resident status, (3) year of completion of residency, (4) type of employment setting (private practice or nonprivate), (5) having an academic affiliation or not, (6) size of practice community (population of less than 500,000 v 500,000 or more), and (7) ratings of clinical and didactic learning experiences regarding that topic during residency training.
Because the first six of these variables are categorical, χ2 analyses were performed to assess differences in interest in each topic. For example, a χ2 analysis was performed to assess whether a greater proportion of one gender or the other (women, men) indicated an interest or not (yes, no) in musculoskeletal and soft tissue disorders. This analysis involved four cells (2 × 2) that crossed gender with interest (i.e., women interested, women not interested; men interested, men not interested). This type of χ2 analysis was repeated for each of the 47 topics in assessing gender differences. Similar sets of 47 analyses assessed differences on the bases of former or current resident status (2 × 2 cells), year of completion of residency (5 × 2 cells), in private practice or not (2 × 2 cells), having an academic affiliation or not (2 × 2 cells), and size of practice community (2 × 2 cells).
To determine the relationship between interest in a topic and ratings of the respondents' learning experiences in that topic during residency, 47 t tests were performed. For example, the mean rating of clinical training in therapeutic injections (based on the continuous 5-point rating scale) was compared between respondents who expressed interest in the topic and those who did not. This type of analysis was repeated for each of the 47 topics.
Because of the multiple comparisons, differences indicated by a p value of less than 0.05 should be interpreted cautiously, because some apparent differences may be due to chance. Somewhat more confidence can be placed in differences indicated by smaller p values.
Characteristics of the sample are displayed in Table 1. Fifty-seven percent (96/168) of the former residents completed the survey. Fifty-two percent (62/120) of male former residents responded, and 71% (34/48) of female former residents responded. All 34 of the then current residents (20 men, 14 women) completed the survey. Year of completion of residency ranged from 1964 to 1995 for the former residents who responded, and year of expected completion for current residents ranged from 1996 to 1998. For former residents, the percentages responding by year of completion of residency were as follows: 1964 to 1969, 33% (5/15); 1970 to 1974, 58% (7/12); 1975 to 1979, 44% (8/18); 1980 to 1984, 56% (15/27); 1985 to 1989, 61% (23/38); 1990 to 1995, 66% (38/58).
Seventy-three percent of the former residents who responded were in private practice, and 41% of those in private practice had an academic affiliation. Nineteen percent of the former residents were in full-time PM&R academic positions (women, 24% [8/34]; men, 16% [10/62]). Nearly two-thirds of the former residents practiced in communities with populations of 500,000 or larger. The mean distribution of work time among clinical practice, research, education, and administration are presented in Figure 1 for the 92 former residents with clinical positions. More than three-fourths of their time was devoted to clinical practice. Notably, less than 3% of their time was devoted to research. Also presented in Figure 1 is the mean distribution of clinical time among electrodiagnostics, inpatient bed service, inpatient consultations, and outpatient services. Inpatient beds and outpatient services accounted for more than 70% of clinical time. Table 2 presents respondents' rankings of the three busiest areas of clinical practice (busiest = rank 1). Back and neck pain, stroke rehabilitation, and musculoskeletal/soft tissue disorders were the most frequently selected areas, accounting for more than 55% of the areas ranked 1. Data from respondents who did not rank the areas (n = 9) were excluded. Also excluded were data from individuals who were not in clinical practice (n = 3) or who were still in training (n = 35). Thus, data were available for 83 people.
Continuing Educational Interests
Interest in the topic was, by far, selected most frequently as the most important consideration when deciding whether to attend an educational activity (Table 3). Provision of CME credits was the second most frequently selected consideration. Presented in Table 4 are the percentages of people interested in each of 48 topics, ordered by overall percentage interested. Findings are presented separately for all 130 respondents, the 48 (37%) women, the 82 (63%) men, the 96 (74%) former residents, and the 34 (26%) current residents. Topics of interest to greater than half of the respondents included musculoskeletal/soft tissue disorders, therapeutic injections/nerve blocks, industrial medicine, back and neck pain rehabilitation, and sports-related disorders. Data were excluded from people who did not rank the considerations for attendance (n = 13), retired persons (n = 2), and current residents (n = 34); resulting data were from 81 respondents.
There were gender differences for 7 (15%) of the 47 topics. Women were more likely than men to be interested in outcome methods and measurements in PM&R (χ2 = 7.08; P < 0.01), research skills (χ2 = 8.27; P < 0.01), grant writing skills (χ2 = 8.11; P < 0.01), mentoring (χ2 = 4.20; P < 0.05), sexuality and disability (χ2 = 11.36; P < 0.001), rehabilitation of women with disability (χ2 = 8.63; P < 0.01), and cultural/ethnic issues among minorities with disability (χ2 = 6.93; P < 0.01). There were no areas in which men were more likely than women to have an interest.
There were significant differences between former and current residents for 10 (21%) of the 47 topics. Former residents were more likely than current residents to be interested in computer applications (χ2 = 7.23; P < 0.01) and pharmacologic issues in rehabilitation (χ2 = 6.67; P < 0.01). Current residents were more likely than former residents to be interested in therapeutic injections/nerve blocks (χ2 = 5.74; P < 0.05), sports-related disorders (χ2 = 10.12; P < 0.01), radiologic diagnosis (χ2 = 4.08; P < 0.05), prosthetics/orthotics (χ2 = 23.81; P < 0.0001), physical modalities (χ2 = 9.44; P < 0.01), cardiopulmonary rehabilitation (χ2 = 20.37; P < 0.0001), cancer rehabilitation (χ2 = 4.62; P < 0.05), and pediatric rehabilitation (χ2 = 10.78; P < 0.01).
Significant differences in interest in four (9%) topics were found to be based on year in which residency was or will be completed (Fig. 2). For purposes of these analyses, former residents who completed residency before 1985 were regrouped into only two categories (1964-1974 and 1975-1984) to avoid very small cell sizes. This yielded five time periods for the analyses. Therapeutic injections (χ2 = 12.82; P < 0.02), sports-related disorders (χ2 = 12.04; P < 0.02), and prosthetics/orthotics (χ2 = 28.65; P < 0.0001) were of interest to a greater percentage of more recent and current residents, whereas geriatric rehabilitation (χ2 = 13.99; P < 0.01) was more likely to be of interest to those who completed their residency longest ago.
For former residents, interest in seven (15%) topics was significantly related to whether the respondent was in private practice (solo or group) or not (federal/VA or full-time PM&R academician; Fig. 3). People not in private practice were more likely than those in private practice to be interested in prosthetics/orthotics (χ2 = 6.70; P < 0.01), neurologic disorders (χ2 = 4.68; P < 0.05), patient and family education (χ2 = 6.17; P < 0.05), inpatient goal setting (χ2 = 4.18; P < 0.05), mentoring (χ2 = 17.53; P < 0.0001), administration (χ2 = 4.71; P < 0.05), and leadership (χ2 = 7.02; P < 0.01). There were no areas in which people in private practice were more likely than those not in private practice to have an interest. For individuals in private practice, two (4%) topics were significantly related to whether the person had an academic affiliation (Fig. 4). Those with an academic affiliation were more likely than those without such affiliation to be interested in research (χ2 = 5.42; P < .05) and grant writing skills (χ2 = 7.47; P < 0.01). No significant difference in topics of interest was related to size of practice community.
Interest in seven (15%) topics was significantly related to the individual's ratings of the clinical and/or didactic learning experiences in that area during residency training (Fig. 5). For six of these seven topics, people who rated their learning experiences more poorly were more likely to be interested in continuing education in that topic. These included therapeutic injections/nerve blocks (clinical: t1798 = 3.35, P < 0.01; didactic: t1843 = 2.42; P < 0.05), prosthetics/orthotics (clinical: t1123 = 2.73, P < 0.01; didactic: t1121 = 3.29, P < 0.01), vocational rehabilitation (clinical: t1119 = 3.29, P < 0.01; didactic: t1117 = 2.13, P < 0.05), ethical issues (didactic: t1116 = 2.41, P < 0.05), computer applications (clinical: t1108.9 = 2.81, P < 0.01), and outcome methods and measurements in PM&R (didactic: t1115 = 2.05; P < 0.05). What is interesting is that people interested in further training in research skills rated their residency training in research skills more highly than did those not interested in the topic (didactic: t1115 = −2.41, P < 0.05).
The desire to conduct this study was driven largely by the time demands that current medical practices place on the ability of physiatrists to attend CME conferences, courses, workshops, and professional meetings. Many variables have changed the way in which physicians decide how they will further their knowledge.9, 10 More information was needed to plan successful, meaningful CME activities to meet the needs of physiatrists at various stages in their careers.
With regard to the generalizability of the results, our sample is roughly comparable to the respondents of the 1996 membership survey of the AAPM&R (n = 1381).8 Thirty percent of their sample were women compared with 37% of ours; 26% of their sample were in solo private practice compared with 31% of our former residents; 31% of their sample were in group practice compared with 42% of our former residents; and 14% of their sample were in an academic practice plan compared with 19% of our former residents. After "Other Nondirect Patient Care Medical Activities" and "Other Activities" were excluded, the AAPM&R sample devoted 64% of their time to direct patient care compared with 76% of our former residents. Fifty-three percent of their sample and 64% of our former residents practiced in metropolitan areas with populations greater than 500,000. Their respondents had been in practice a mean of 11 yr compared with a mean of 10 yr for our former residents. The major difference between the two samples is the inclusion of current residents (n = 34; 25%) in our sample.
CME planners must attempt to determine the most significant combination of factors to attract participants to their activities. In planning meetings, various factors are proposed as being more or less important. It is gratifying to find that interest in the topic continues to be the most important consideration for determining attendance at a CME activity for physiatrists. Because specified amounts of CME credits are required in most states, it is not surprising that CME credit is the second most important consideration in the decision to spend time on CME. It was somewhat unexpected to find that "known presenter" was less important than other considerations, such as time of day, day of week, distance from practice, and duration of program. CME planners usually make considerable efforts to identify speakers who have name recognition, and speaker honoraria are often a large part of the budget. This survey finding reflects changes in the health care environment that have increased the value that physiatrists place on their time. Many of the factors that were more important than "known presenter" were related to time.
Today's health care changes are also reflected in the topic areas of greatest interest. They reflect the areas of physiatric clinical practice that have expanded during the past several years. Outpatient rehabilitation facilities have been exploding in growth, largely in the areas of the top five topics of interest: musculoskeletal/soft tissue disorders, therapeutic injections/nerve blocks, industrial medicine, back and neck pain, and sports-related disorders.11 The next ranked topics are in the areas of diagnostics and computer and business practices. Physiatrists are among many physicians practicing in today's managed care, capitated-fees market who have an increased need for knowledge in business management. It is no longer sufficient to delegate these activities to others and not have a personal understanding of business practices.
Another observation regarding the top 10 topics of interest becomes apparent when contrasting them with the 10 items at the bottom of the list. It could be speculated that topics of greatest interest overall are medical technical skill areas that are predominately in the domain of the physician's responsibility (musculoskeletal/soft tissue disorders, therapeutic injections, industrial medicine, back and neck pain). Many of the topics of least interest are less medically technical, and some, such as substance abuse and speech/language disorders, may be viewed as the primary responsibility of other rehabilitation team members.
The differences between topics of interest to women and men are difficult to explain. Perhaps the reason that more women are interested in research, grant writing skills, and mentoring is that proportionately more women respondents are in academic settings. Their greater interest in women with disabilities possibly could be explained by increased personal sensitivity about the subject. An explanation of the greater interest of women in the topics of sexuality and disability and cultural/ethnic issues among minorities with disability is not obvious.
The differences in interest between recent and former residents were significant for four topics. The greater interest of more recent residents in the topic of therapeutic injections could be explained by the increase in knowledge, new pharmacology, and the increase in the use of therapeutic injections by physiatrists in the past few years. Physiatric services to individuals with sports-related disorders also have increased in recent years as part of the move toward more outpatient services and the identification of a niche for physiatric practice in ambulatory, preventive care.11 The variance in interest in prosthetics/orthotics could also be related to physiatrists' seeing increased value in developing an outpatient/ambulatory practice. The significantly greater interest in geriatric rehabilitation among the former rather than the recent residents could be reflective of the aging of the patients who have been under their care for many years or of a more personal interest as they themselves age. Knowing which topic areas evoke significant differences in interest between recent and former residents can be helpful when targeting the announcement of the availability of the CME activity and when setting the pace of the activity.
It is unclear why there are differences in topics of interest in the seven areas between private practice and nonprivate practice (Fig. 4); however, because there are areas in which these differences are great, this warrants further study.
It is noteworthy that, for the most part, our respondents expressed interest in learning more about topics that they believed were gaps in their residency training. The one exception was with regard to research skills. The reasons for these differences are somewhat opaque. This phenomenon has not been documented in modern CME literature and merits further exploration.
Planners of CME can be guided by information from surveys such as this, which is more accurate and representative of the preferences and impressions of the entire target audience. CME planners are most often academic, nonprivate practitioners, and care must be taken that planning is not done entirely from personal interests and observations because this study indicates that there are significant differences between the interests of academic, nonprivate practitioners and those in private settings, regardless of whether they have academic affiliations.
CME is a large, expensive industry, and it must be relevant and cost-effective to succeed in today's health care environment. New topics of interest continue to emerge as biological and technological advances are made (e.g., telemedicine, information via Internet). More research is needed to continue to determine the most effective and efficient ways to deliver CME to meet the needs of physiatrists at various stages in their careers and within the time and financial constraints imposed by today's clinical practice.
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Continuing Call for Papers
The primary purpose of The American Journal of Physical Medicine & Rehabilitation (AJPM&R) is to facilitate the dissemination of scholarly work on the practice, research and educational aspects of physical medicine and rehabilitation. Toward fulfilling its purpose, the AJPM&R invites submission of original papers, particularly in the categories given below, for consideration to publish:
Scientific research papers: Scientific investigations that advance the field of physiatric medicine.
Literature reviews: Critical summaries and assessments of previously published information on topics related to the field of physical medicine and rehabilitation. Because of space limitations, reviews will be accepted only under special circumstances.
Case studies: Presentations of the diagnosis, treatment and outcomes of individual cases of specific conditions to improve patient care.
Brief reports: Short articles reporting on research techniques, statistical techniques, educational and clinical aspects of physical medicine and rehabilitation.
Clinical notes: Comments on patient diagnosis or treatment resulting from personal clinical experience.
Commentaries: Indepth, editorial-like, articles on matters relating to the clinical, scientific and educational aspects of physical medicine and rehabilitation.
Letters to the Editor: Objective critiques and comments covering material published in a recent issue of the Journal.